Index Child Questionnaire

Appendix D3 (Questionnaire about Index child)

Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/20xx

Form Approved

OMB No. 0920-15AFJ

Exp. Date xx/xx/20xx

Household ID#

Date

Interviewer's Initials

Public reporting burden of this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).

A. Location Questions (To be completed by field technician and participant)

1. For each approximate time period given below, indicate where your child was located. Select any locations that apply to the time period.

	Home	Outdoor area at home	Other residence (ex. babysitter's house)	Store	Restaurant	Church	Other indoor location	Park	Bus/train stop	On or near street	Parking garage	Other outdoor location	In vehicle	Don’t know/Refused to answer
5:00 am - 5:29 am
5:30 am - 5:59 am
6:00 am - 6:29 am
6:30 am - 6:59 am
7:00 am - 7:29 am
7:30 am - 7:59 am
8:00 am - 8:29 am
8:30 am - 8:59 am
9:00 am - 9:29 am
9:30 am - 9:59 am
10:00 am - 10:29 am
10:30 am - 10:59 am
11:00 am - 11:29 am
11:30 am - 11:59 am
12:00 pm - 12:29 pm
12:30 pm - 12:59 pm
1:00 pm - 1:29 pm
1:30 pm - 1:59 pm
2:00 pm - 2:29 pm
2:30 pm - 2:59 pm
3:00 pm - 3:29 pm
3:30 pm - 3:59 pm
4:00 pm - 4:29 pm
4:30 pm - 4:59 pm
5:00 pm - 5:29 pm
5:30 pm - 5:59 pm
6:00 pm - 6:29 pm
6:30 pm - 6:59 pm
7:00 pm - 7:29 pm
7:30 pm - 7:59 pm
8:00 pm - 8:29 pm
8:30 pm - 8:59 pm
9:00 pm - 9:29 pm
9:30 pm - 9:59 pm
10:00 pm - 10:29 pm
10:30 pm - 10:59 pm
11:00 pm - 11:29 pm
11:30 pm - 11:59 pm

Bottom of Form

2. Look back at the answers to question 1. Based on yesterday's day of the week, do these locations represent a fairly typical or normal day for your child? For example, if yesterday was a weekday, is this a typical weekday schedule for your child?

Yes

No

Don't know/Refused to answer

B. Activity Questions (To be completed by field technician and participant)

3. For each approximate time period given below, indicate activities your child performed. Select all that apply for the time period.

	Dress, groom or bathe	Eat	Watch TV	Play	Use computer or play video games	Read or do school work	Take care of younger children	Chores	Exercise	Play with pet	Arts and crafts	Sleep	Don’t know/Refused to answer	None of these
5:00 am - 5:29 am
5:30 am - 5:59 am
6:00 am - 6:29 am
6:30 am - 6:59 am
7:00 am - 7:29 am
7:30 am - 7:59 am
8:00 am - 8:29 am
8:30 am - 8:59 am
9:00 am - 9:29 am
9:30 am - 9:59 am
10:00 am - 10:29 am
10:30 am - 10:59 am
11:00 am - 11:29 am
11:30 am - 11:59 am
12:00 pm - 12:29 pm
12:30 pm - 12:59 pm
1:00 pm - 1:29 pm
1:30 pm - 1:59 pm
2:00 pm - 2:29 pm
2:30 pm - 2:59 pm
3:00 pm - 3:29 pm
3:30 pm - 3:59 pm
4:00 pm - 4:29 pm
4:30 pm - 4:59 pm
5:00 pm - 5:29 pm
5:30 pm - 5:59 pm
6:00 pm - 6:29 pm
6:30 pm - 6:59 pm
7:00 pm - 7:29 pm
7:30 pm - 7:59 pm
8:00 pm - 8:29 pm
8:30 pm - 8:59 pm
9:00 pm - 9:29 pm
9:30 pm - 9:59 pm
10:00 pm - 10:29 pm
10:30 pm - 10:59 pm
11:00 pm - 11:29 pm
11:30 pm - 11:59 pm

Bottom of Form

4. When at home, which room does your child sleep in?

Child’s bedroom

Mother’s bedroom

Living room

Other room in the home

 Don’t know/Refused to answer

5. When indoors at home and awake, where does your child spend the most time?

Living room/family room

Child’s bedroom

Mother’s bedroom

Kitchen

Other room in the home

Don’t know/Refused to answer

6. When at home, how much time per day does your child spend sitting/playing/lying on the floor?

Less than 30 minutes

30 minutes

1 hr

1.5 hrs

2 hrs

2.5 hrs

3 hrs

More than 3 hrs

Don’t know/Refused to answer

7. Is the floor she or he plays on carpeted?

Carpeted

Not carpeted

Partially carpeted

Child does not play/sit/lie on the floor

Don’t know/Refused to answer

8. Typically, how much time per day does your child play outside at home (yard, common area, playground)?

0-15 minutes

15-30 minutes

30 minutes to 1 hour

1-2 hours

2-3 hours

More than 3 hours

Don’t know/Refused to answer

9. Typically, how much time per day does your child play outside at school/daycare?

0-15 minutes

15-30 minutes

30 minutes to 1 hour

1-2 hours

2-3 hours

More than 3 hours

Don’t know/Refused to answer

10. How much time per day does your child play at local parks?

0-15 minutes

15-30 minutes

30 minutes to 1 hour

1-2 hours

2-3 hours

More than 3 hours

Don’t know/Refused to answer

11. How often does your child's sleep get interrupted (e.g., by noise or other disturbance in the community)?

Never

Once a month

Once a week

More than once a week

Don't know/Refused to answer

12. How many times did your child wash his/her hands yesterday?

1

2

3

4

5

6

7

More than 7

Don't know/Refused to answer

13. How many times a week does your child bathe?

1

2

3

4

5

6

7

More than 7

Don't know/Refused to answer

C. Diet Questions (To be completed by field technician and participant)

14. How many meals did your child eat yesterday (e.g., breakfast, lunch, dinner), not counting snacks?

1

2

3

4

5

6

7

More than 7

Don't know/Refused to answer

15. For each MEAL your child ate, what best describes the meal? If your child ate more than 4 meals, just answer for the first 4.

	Meal prepared by school	Meal made at home from ready-made frozen or canned food	Fast food meal	Restaurant meal (not fast food)	Meal made at home from scratch	Don't know/Refused to answer
Meal 1
Meal 2
Meal 3
Meal 4

16. On average, how often does your child eat/drink the following foods and beverages?

	Once a month or less	2-3 times per month	1-2 times per week	3-4 times per week	5-6 times per week	Once a day	2-3 times per day	4-5 times per day	6 or more times per day
Poultry
Beef
Pork
Fish
Shellfish
Rice
Other dairy products (not milk)
Leafy green vegetables
Other vegetables (not potatoes)
Potatoes
Breads
Fruit
Snack Foods
Milk
Fruit juice
Soda
Tap water or beverage made with tap water

17. How often do you purchase food at each of these types of stores? (Field Technician: If Appendix D2 has been completed for the sibling, please copy those answers here, do not ask the question a second time).

	Never	Once a month	Once a week	2 times a week	3 times a week	More than 3 times a week
Supermarket or large grocery store
Small grocery store (e.g., small store in your neighborhood that mainly sells food)
Farmer's or outdoor market
Store in a gas station
Discount store (e.g., a dollar store, Big Lots)

18. How often does your child eat at each of these types of restaurants?

	Never	Once a month	Once a week	2 times a week	3 times a week	More than 3 times a week
Fast food
Sit - down restaurant
Food truck or stand